PIERCING MEDICAL DISCLOSURE FORM

Date: _____________________ Please check any conditions listed below that apply to you. High / Low Blood Pressure _______ Diabetes _______ HIV / AIDS _______ Heart Condition _______ Faint or Dizzy _______ Epilepsy _______ Hemophilia _______ Eczema/Psoriasis _______ Infections _______ T.B. _______ Scarring/Keloiding _______ Herpes _______ Asthma _______ Hepatitis _______ Pregnant _______ Nursing _______ Blood Thinners _______ _______ I am not / will not be under the influence during the procedure. _______ To my knowledge, I dont have any physical, mental or medical impairment, condition, or disability which might affect my well-being as a direct or indirect result of my decision to have any piercing-related work performed on me. _______ I agree to follow all instructions concerning the care of my piercing while it is healing and afterward. _______ I agree that any follow up work needed, due to my own negligence, will be done at my own expense. _______ Being of sound mind and body, I hereby release any and all persons representing Metal Face Body Piercings from all responsibility, now and in perpetuity. _______ I accept any and all responsibility myself for any consequences that might stem from my decision to have any piercing-related work done by Metal Face Body Piercings. _______ I agree for myself, my heirs, assigns, and legal representatives to hold harmless from all damages, actions, causes of action, claim judgments, costs of litigation, attorneys fees, and all other costs and expenses which might arise from my decision to have any piercing-related work done by Metal Face Body Piercings. _______ I agree to pay for any and all damages or injuries to any and all persons and property of Serena Slevin, belonging to Serena Slevin, or any other person to whom Metal Face Body Piercings and representatives may become liable contractually or by operation of law, caused by, or resulting from my decision to have any piercingrelated work done by Metal Face Body Piercings. _______ I agree that these waivers also pertain to and are designed to protect any and all establishments where Metal Face Body Piercings conducts business. _______ I have read and understood each of the above paragraphs. Do you have any allergies to medication or topical solutions? _____________________________________________________________________________________________ Do you have any medical conditions we should be aware of prior to performing this procedure? _____________________________________________________________________________________________ _______ I have been provided with information describing the body piercing procedure to be performed and instructions on aftercare. I have been made aware that I have any signs of symptoms of infection, such as swelling, pain, redness, warmth, fever, unusual discharge or odor to contact my physician. It is also my responsibility to take care of my new body piercing site according to the instructions provided, both verbally and in writing. Piercers name: __________________________ Location of piercing: ____________________________________ Piercers signature: _____________________________________________________________________________ Skin condition: ________________________________________________________________________________ Jewelry used: ___________________________________________

BODY PIERCING RELEASE FORM

Name: _________________________________________________________________ Date: _____/_____/_____ Address:________________________________________ City:_______________________ State:__________ Zip:_______________ Phone:______________________________________ Date of Birth: _____/_____/_____ Race: _____________ Sex: _____________ Emergency Contact:______________________________________ Phone:______________________________ Address:_______________________________________________ Physician*:____________________________________________________Phone:_______________________ Address:___________________________________________________________________________________

Bleeding Disorders: Yes ____ No ____

If Yes List: _________________________________________________

_____________________________________________________________________________________________ Allergies / Skin Conditions: (i.e. Iodine, topical solutions, medications, latex, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ I am at least 18 years or have parental consent. I represent and warrant to Metal Face Body Piercings that the above information is true and correct. I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have and allergic reaction to the piercing or process involved in the piercing and further acknowledge that such reaction is possible. I have had the aftercare instructions explained to me. I understand all the aftercare instructions as they were explained. I have been given a copy of my aftercare instructions. I agree to follow all instructions concerning the care of my piercing while it is healing. I acknowledge infection is always possible as a result of obtaining a piercing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. I realize that my piercing is being done in a sterile environment with sterile instruments. I accept any and all responsibility myself for any consequences that might arise from my decision to have any piercing work done by Metal Face Body Piercings.

Signed ______________________________________________ Date: ______________ Parent or Guardian Signature ______________________________ Date: ______________ (only if under the age of 18)

PARENTAL CONSENT FORM

I, ___________________________________ [parent/guardians name], do hereby give my consent and permission for ___________________________________ [minors name] to obtain a piercing from: Metal Face Body Piercings. In doing so, I accept full legal and moral responsibility for said piercing and assume all liability associated with the same. By signing this consent, I confirm that I have read and understand all information on the medical disclosure and release liability form and the completed care instructions. I agree to supervise the aftercare procedures to insure proper healing of said piercing. Parents full name: ___________________________________________________________ Signature: _________________________________________________________________ Parents license number: ______________________________________________________